Risk-based management of international sporting events during the COVID-19 pandemic

Abstract Mass gatherings include a diverse range of events such as sporting competitions, religious ceremonies, entertainment activities, political rallies and cultural celebrations, which have important implications for population well-being. However, if not managed properly, these events can amplify health risks including those related to communicable diseases, and place undue strain on health systems in host countries and potentially in attendees’ home countries, upon their return. The coronavirus disease 2019 (COVID-19) pandemic has provided a unique opportunity to evaluate the risk factors associated with mass gatherings and the effectiveness of applying mitigation measures during infectious disease emergencies. The pandemic has also allowed event organizers and health officials to identify best practices for mass gathering planning in host countries. To guide decisions about whether to hold, postpone, modify or cancel a mass gathering during the COVID-19 pandemic, the World Health Organization and its partners developed normative guidance and derivative tools promoting a risk-based approach to mass gathering planning. This approach involves three steps to guide decision-making around mass gatherings: risk evaluation, risk mitigation and risk communication. The approach was applied in the planning and execution of several mass gathering events, including the Tokyo 2020 and Beijing 2022 Olympic and Paralympic Games. Lessons identified from these large-scale international events offer insights into the planning and implementation of mass gathering events during a pandemic, and the broader impacts of such events on society. These lessons may also further inform and refine planning for future mass gatherings.


Introduction
Mass gatherings are characterized by the concentration of people at a specific location for a specific purpose over a set period.Such gatherings encompass a diverse range of events, including sporting competitions, religious ceremonies, entertainment events, political rallies and cultural celebrations.Mass gatherings are not merely recreational; rather, they have important implications for population health and well-being.If not managed properly, however, mass gatherings may amplify health risks including those related to communicable diseases, and placing undue strain on health systems in host countries and potentially in attendees' home countries, upon their return.The coronavirus disease 2019 (COVID-19) pandemic and previous large-scale infectious disease emergencies, such as severe acute respiratory syndrome (SARS) (2003), Middle East respiratory syndrome (MERS) (2012), H1N1 influenza (2009) and Zika (2016), have underscored how epidemics and pandemics can disrupt mass gatherings, and how such events could potentially worsen the spread and impact of high-risk outbreaks. 1,2As such, the World Health Organization (WHO) has prioritized identifying risk-based approaches to hold mass gatherings safely during pandemics and other public health emergencies of international concern, and published relevant guidance. 3he COVID-19 pandemic has provided a unique opportunity to evaluate risk factors associated with mass gatherings and the effectiveness of risk mitigation measures applied to such events during major outbreaks.The pandemic has also enabled event organizers and health experts to identify best practices for mass gathering planning in host countries and highlighted the positive long-term benefits, or legacies, 3 of mass gathering events when they are implemented thoughtfully, with appropriate planning, resources and engagement.
To support decisions about whether to hold, postpone, modify or cancel a mass gathering during COVID-19, WHO has adapted existing recommendations on mass gatherings to the pandemic context and developed normative guidance and related tools.The guidance promotes risk-based approaches to mass gathering planning amid an evolving public health emergency.

Planning mass gatherings
In line with WHO's general guidance, 3 when planning mass gatherings, decision-makers should identify public health risks and assess them in relation to how risks may affect and be amplified by these events, to devise adequate precautionary measures.In the context of COVID-19, this exercise focused on the likelihood and consequences of SARS coronavirus 2 (SARS-CoV-2) spreading in the host country and participants' home countries.Through implementing precautionary measures, WHO aimed at making mass gatherings as safe as possible by preventing surges in COVID-19 cases and deaths.
Every mass gathering is unique; as such, no one-size-fitsall solution to ensuring safety exists, which is particularly true for risks associated with communicable diseases.Therefore, in the face of COVID-19's dynamic evolution, the global health community expected that precautionary measures would vary between countries and over time.Nevertheless, having consolidated, consistent and structured approaches to manage risk associated with planned events is essential both Bull World Health Organ 2024;102:608-614| doi: http://dx.doi.org/10.2471/BLT.23.290034   Albis Francesco Gabrielli et al.
Preparations for international sporting events during a pandemic in terms of preparedness and response. 4[7][8][9][10][11] With these considerations in mind, in early 2020 WHO convened global scientists (from academia, public health agencies and research institutions, among others) as part of the COVID-19 Mass Gatherings expert group to adapt existing general riskbased guidance on mass gatherings, and conceptualize a tailored approach that would support decision-making around mass gatherings in the context of the COVID-19 pandemic. 12WHO initiated these efforts in response to requests from Member States, international organizations and event planners.Although WHO does not have a mandate to enforce any action with respect to holding, delaying or modifying mass gathering events, the Organization does play a role in developing technical guidance on evidence-based best practices and disseminating it among relevant stakeholders to support informed decision-making. 13WHO's role in this regard aligns with Article 43 of the International Health Regulations (2005), which makes provisions for States Parties to implement measures concerning travellers taking part in mass congregations. 14

A risk-based approach to COVID-19
As a derivative product of WHO's general guidance on mass gatherings, the Organization adopted the COVID-19 risk-based approach as an official policy and published it as interim guidance; the principles of the approach were also articulated in a WHO policy brief. 10,11he approach is adaptable to gatherings of any size and type -as well as to any SARS-CoV-2 transmission scenarioand consists of three steps.First, risk evaluation, which aims at identifying and quantifying the baseline risks associated with the gathering.Second, risk mitigation, which proposes a series of precautionary measures aimed at decreasing the baseline risk of the gathering.Third, risk communication, which prompts the timely and proactive dissemination of information on the process, rationale, purpose and limits of the precautionary measures adopted, with the aim of enhancing adherence by event attendees.
The risk evaluation step involves examining key characteristics of the mass gathering event in question, as well as the context in which the event takes place.To assess the likelihood of SARS-CoV-2 transmission and its public health consequences, this step encourages decision-makers to consider key aspects such as the epidemiological context of the host community; influxes of mass gathering participants and spectators; characteristics of the venue; health needs and risk profiles of attendees; and potential risk-taking behaviours connected to the event.Other critical considerations include local health system capacities; vaccination coverage; variants of concern; and levels of compliance with public health and social measures in place in the host country.
Risk mitigation focuses on a package of multisectoral actions that aim at enhancing public health and preserving safety; these may be implemented before, during and after the event.Examples of relevant mitigation measures include establishing or strengthening coordination between all event stakeholders, bolstering capacities among designated staff and establishing eventbased surveillance mechanisms.Risk mitigation also embodies the value of enforcing basic measures such as physical distancing, hand hygiene, mask use, screening attendees at port of entry or at venues, and monitoring attendee movement during the event.
The risk communication step offers guidance on deploying robust community engagement strategies before, during and after the event in question, such as using visual displays or audio reminders, website postings, social media or other communication platforms.Risk communication may also entail social media monitoring and infodemic management.Notably, this step underscores the importance of conveying to attendees and event planners the need for personal responsibility and respectful behaviour, as well as the message that eliminating all potential risk is impossible.
To further operationalize the guidance, upon WHO's request and under its technical oversight, the WHO Collabo-rating Centre for Global Health Security at the Johns Hopkins University, with support from the WHO COVID-19 Mass Gatherings expert group, developed several risk assessment tools that were published as WHO products and underwent subsequent revisions.6][17] These tools account for the unique planning considerations associated with such gatherings.Sporting events, for example, may present varying levels of risk for athletes, team officials and spectators due to the nature of the sport in question. 18,19Physical distancing may also be impossible for certain athletes during competition.Additionally, while athletes are typically young, healthy individuals, spectators may include more medically vulnerable individuals.
As the pandemic unfolded, the same authors systematically updated both the guidance and the tools to reflect the evolving nature of WHO recommendations on COVID-19.Best practices on planning and implementation of mass gatherings emerged as events were implemented and reviewed, and efforts were made to improve the usability of the tools.
Through different normative mechanisms, WHO has recommended that Member States adopt the risk-based approach when planning for mass gatherings during the COVID-19 pandemic.To monitor mass gathering decision-making and implementation through COVID-19, WHO and the WHO Collaborating Centre for Global Health Security at the Johns Hopkins University developed and maintained a global database of mass gatherings since the beginning of the pandemic.By 31 December 2023, when the database was discontinued a few months after WHO declared that COVID-19 no longer constituted a public health emergency of international concern (5 May 2023), 164 WHO Member States and 11 other countries, territories and areas reported having applied the risk-based approach to at least one mass gathering event to decide whether or how it should be held.By the same date, the number of recorded mass gatherings for 2020-2023 was 5852, of which 52.3% (3060) had applied WHO's risk-based approach in their decision-making process. 20,21

Policy & practice
bly, the database mainly captured larger events with international participation; as such, the above figure cannot be considered representative of the volume of mass gatherings held globally during the pandemic.

Tokyo 2020 and Beijing 2022
Among the mass gatherings whose planning and execution relied on WHO's risk-based approach, two major international sporting events held during the COVID-19 pandemic merit particular consideration due to their size, international participation and high visibility: the 2020 Summer Olympic and Paralympic Games held in Tokyo, Japan in July−September 2021, and the 2022 Winter Olympic and Paralympic Games held in Beijing, China in February−March 2022.Close, collaborative partnerships between the International Olympic Committee, the International Paralympic Committee, the countries hosting these events and WHO formed the cornerstone of these efforts.
In preparation for Tokyo 2020 and Beijing 2022, through the International Olympic Committee and the International Paralympic Committee, the two host countries' organizing committees invited WHO to join dedicated working groups.These working groups convened all actors involved in the events, and offered a platform for policy dialogue related to health in general and COVID-19 in particular.WHO's role involved sharing guidance and providing tailored advice to the other actors, notably to the national organizing committees that represented each country's government -and that are ultimately responsible for the events.These efforts enabled informed decision-making for health-related aspects of both events, and facilitated the development of event-specific normative products that were based on WHO recommendations.Notably, the International Olympic Committee and the International Paralympic Committee, in collaboration with the organizing committees of Tokyo 2020 and Beijing 2022, published two sets of Playbooks 22,23 featuring protocols for public safety, COVID-19 vaccination, routine testing, laboratory sequencing, onsite precautionary measures and in-country travel restrictions.The Playbooks also introduced innovative mitigation measures such as bubbles and closed loops (that is, approaches that allow close, in-person interactions only among a defined group of people, thus limiting the risk of transmission from and to people external to the bubble or loop), and articulated roles and responsibilities for COVID-19 compliance officers.
In line with its mandate, WHO also activated an internal coordination mechanism to assess and monitor health-related risks, and established daily reporting systems between its headquarters, regional offices and relevant WHO country offices, based on which WHO produced daily and weekly situational reports.Through its convening power, WHO facilitated close cooperation among relevant international, national and local health agencies and other stakeholders for both events.WHO also scaled up eventbased surveillance for COVID-19, other outbreak-prone communicable diseases and other acute events, 24 with the goals of detecting and assessing emergent signals of public health concern, monitoring infodemics, and quantifying and analysing relevant public health information from digital and social media (such as Twitter -now X -Facebook, Instagram, YouTube, blogs and other forums).These methods of event-based surveillance enabled event organizers to track the spread of misinformation about COVID-19 and address concerns about public safety.Additionally, the robust risk communication measures implemented by the host countries' organizing committees in conjunction with both events and through different channels (visual displays, audio reminders, website postings, mobile applications, social media and helplines among others) enabled securing buy-in and cooperation from spectators, athletes, event staff, the media and other stakeholders.Constant communication and information sharing between Member States, event organizers, WHO and the public were essential components of implementing the risk-based approach, as this approach facilitated taking evidence-based decisions.

Challenges and lessons learnt
During and after Tokyo 2020 and Beijing 2022, WHO informally convened at regular intervals the WHO COVID-19 Mass Gatherings expert group to share advice, review iterations of technical guidance and contribute to discussions among all stakeholders.Notably, sharing information with partners about potential public health risks, documenting best practices, reviewing challenges and identifying lessons further cemented the long-term benefits generated by both events, that is, their legacy. 3The main reflections of these focus group discussions coordinated by WHO are presented below.
Overall, Tokyo 2020 and Beijing 2022 yielded rich lessons and best practices for planning complex international events amid an evolving public health emergency, notably with regard to riskbased decision-making.These lessons, in turn, may be more broadly applicable to future mass gatherings of all types.
First, the decision to modify, postpone or cancel a mass gathering often depends on financial considerations in addition to health and safety concerns.Though applying the risk-based approach can help facilitate safe and successful event delivery -which, in turn, may generate revenue for host countries and organizers and yield important psychosocial benefits for participants and spectators -applying precautionary measures clearly also requires significant levels of human and financial resources.Event organizers, therefore, must account for these factors when planning gatherings of all sizes.
Second, planning considerations should not be limited to the event itself; rather, they must also encompass the social context in which the event takes place.For example, although the organizers of Tokyo 2020 and Beijing 2022 successfully enforced strict safety protocols within event venues, promoting community adherence to such protocols outside official venues proved challenging.Planners must therefore apply a holistic approach, paying close attention to public health and social measures; transportation between events; accommodations; and individual behaviours that might lead to side gatherings, unplanned congregation and unstructured socialization in public spaces or close quarters.
Preparations for international sporting events during a pandemic planning from its inception to ensure that all considerations and concerns are identified early, shared and incorporated into decision-making processes around the gathering in question.In many cases, earning stakeholder buy-in also encourages acceptance of changes to safety policies and plans -which, in turn, may improve compliance with precautionary measures at the event itself.Fourth, communication is a particularly important component of delivering safe and successful mass gatherings.This aspect includes disseminating public health messages regularly, demonstrating transparency in the decision-making process, highlighting the importance of complying with risk mitigation measures and monitoring both media output and public opinion.In this regard, webbased tools have emerged as important assets for monitoring epidemiological trends, sharing detailed event schedules and disseminating up-to-date guidance on public health and social measures applied at event venues.For instance, dashboards and mobile applications can enable spectators to assess personal risks during travel, while also allowing health authorities and event organizers to calibrate public health and social measures and risk communication activities accordingly.
Fifth, although Tokyo 2020 and Beijing 2022 were not significant drivers of COVID-19 infections, illness or hospitalizations, their implementation amid ongoing COVID-19 surges did attract attention and stimulate debate, which may have negatively shaped public perceptions of these events.This consideration underscores the importance of addressing public concerns about the negative health consequences of mass gatherings, including the unintended outcomes of risk mitigation measures applied, such as the potential marginalization of specific communities by selective application of such measures, or about unfair treatment for certain types of events.For example, when sporting events are permitted to continue during public health emergencies, but religious congregations are paused.Other equity-related considerations include athletes' perceptions of fairness in how risk mitigation measures are applied to different sports, or to different competitors within the same sport, such as with respect to time allotted for training and access to training facilities.Sixth, while safety should always remain a top priority in event planning, organizers must strike a balance between mitigating the health risks associated with holding an event and acknowledging the event's anticipated health, spiritual, emotional and financial benefits.Applying a risk-based approach can help event planners safely adapt to evolving epidemiological contexts and varying levels of health system capacity, especially during protracted emergencies like COVID-19, and facilitate efforts to strike a balance between risks and benefits.While striking this balance often proves challenging, it can also stimulate innovative approaches to risk assessment and public health practice, as exemplified by these major sporting events.
Seventh, lessons identified from Tokyo 2020 and Beijing 2022 further underscore the contrast between organizing large-scale sporting events and grassroots sports gatherings during the COVID-19 pandemic.Although the economic stakes of modifying, postponing or cancelling large-scale events are much higher, the institutions planning these events are more likely to have the financial means to withstand such measures.Although organizers of grassroots sports events have ingeniously adapted to the constraints posed by COVID-19, 25 smaller events -which largely rely on ticket sales to generate revenue versus sponsorships or television rights -remain disproportionately affected by limited access to the guaranteed audiences, levels of capital and human resources required to implement certain precautionary measures.Similarly, small business enterprises may be disproportionately affected by industry event cancellations and postponements.Policy-makers, therefore, should ensure that risk mitigation directives do not inadvertently exacerbate baseline societal inequities or create unbalanced burdens for smaller-scale gatherings.
Eighth, while the experiences of Tokyo 2020 and Beijing 2022 have helped generate best practices for mass gathering preparedness, they have also underscored the lack of routine mechanisms for codifying, sharing and institutionalizing lessons identified from mass gatherings held during public health emergencies.Conducting in-depth case studies illustrating how the risk-based approach was applied and calibrated across diverse contexts -as well as providing platforms to share experiences between event organizers, public health experts and other relevant stakeholders -could help expand the evidence base for best practices in mass gathering preparedness.
Finally, metrics to evaluate successes and failures in mass gathering delivery are needed.Qualitative analyses of the perceptions and views of event workers, athletes, spectators and other stakeholders involved in delivering the event in question could inform development of such metrics.Quantitative analyses that examine cases of disease connected to gatherings, identify chains of transmission leading to secondary or tertiary cases, and compare burdens of disease across host jurisdictions could serve as additional metrics of success.

Conclusion
Mass gatherings should be regarded as integral parts of society, as they provide a broad range of financial, public health and social benefits to host countries, participants and spectators; promote local and global economies; and support legacies of health systems strengthening -through enhanced surveillance and measures for prevention, preparedness and response that remain in place after the event -and knowledge sharing.With appropriate planning and early, proactive engagement of all relevant stakeholders, mass gatherings can be held successfully, including amidst a pandemic, and contribute to increased public awareness of health threats, stronger public health systems, improved partnerships between sectors and conducive environments for safe and healthy participation in public, civic and private life. 3Such legacies are especially valuable in settings that host gatherings regularly, and can ensure swift responses to a wide range of complex health risks. 26By enforcing mass gathering planning considerations within broader frameworks for public health preparedness, event planners, decision-makers and practitioners can lay the groundwork for safe, successful events amid emerging and evolving public health crises.